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Inaugural KEYSTONE Course on Health Policy and Systems Research 2015

Health System and Health Policy Frameworks- 1

   

 

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Health Systems and Health Policy Frameworks - 1

Kabir Sheikh

23 February 2015 

   

 

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• DEFINITIONS• HEALTH SYSTEM FRAMEWORKS• HEALTH POLICY FRAMEWORKS

   

 

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DEFINITIONS

   

 

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What is a health system?

• A health system is the sum total of all the organizations, institutions and resources whose primary purpose is to improve health

• A well functioning health system responds to a population’s needs and expectations by:– improving the health status of individuals, families and communities – defending the population against what threatens its health– protecting people against the financial consequences of ill-health– providing equitable access to people-centred care 

www.who.int

   

 

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What is Policy?“Whatever governments choose to do 

or not to do” Dye 1984

“… the manner in which problems get conceptualized and brought to government; institutions formulate alternatives and select solutions; and solutions get implemented, evaluated and revised” Sabatier 1999

“Decisions (in the public and private sector)… taken by those with responsibility for a given area, e.g. health, education, environment or trade” Buse et al. 2005

Decisions with a Purpose

   

 

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HEALTH SYSTEM FRAMEWORKS

   

 

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1. SYSTEM FUNCTIONS

Systems defined on basis of their utility, problems mainly relate to efficiency

Decisions are concentrated, flow in one direction

Policy content not problematized

E.g. WHO ‘building blocks’

International

National

Subnational

Local

ARENA

Systems Human Resources, Finance, Medicines & technology, Organizational structure, Service infrastructure, Information systems

Outputs

Outcomes

Policy Decisions

   

 

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Three key goals (WHO – WHR 2000)

1) Improvement in health : ‘health status of the entire population ..over people’s whole life cycle, taking account of both premature mortality and disability.’

2) Responsiveness: ‘how the system performs relative to non-health aspects, meeting a population’s expectations of how it should be treated by providers of prevention, care or non-personal services’– Respect for persons: confidentiality, autonomy– Client orientation: prompt attention, amenities, choice 

3. Health System Goals

   

 

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3) Fair financing : ‘the risks each household faces due to the costs of the health system are distributed according to ability to pay rather than to the risk of illness: a fairly financed system ensures financial protection for everyone..’– Unexpected costs:  reduce out of pocket payment (OOP)– Contribution to total costs:  richer households contribute 

proportionally more than poorer households (progressive)

4) Now combined as ‘universal health coverage’: “access to key promotive, preventive, curative and rehabilitative health interventions for all at an affordable cost”. (WHA 2005 58.33)

3. Health System Goals

   

 

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Links between functions & goals

WHO – WHR 2000

   

 

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Systems ‘Software’Ideas and interests, Values 

and normsRelationships and power, 

Systems ‘Hardware’Human Resources, Finance, Medicines & technology, Organizational structure, Service infrastructure, Information systems

International

National

Subnational

Local

ARENA2. COMPLEX SYSTEMS

Decisions are diffused through the system, focus on non-linear relationships

‘Software’ critical to health systems performance

Problems (and solutions) are related to (understanding) complexity 

See Frenk 1994, de Savigny and Adam 2009

   

 

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A health system

Health• Beyond sickness

– mental & physical health– social wellbeing

• Beyond the individual– actors/agents promoting 

health & wellbeing– domestic/national AND 

international factors impacting on health and HS agents

A complex adaptive system• A set of interacting elements• More than the sum of the 

parts

• Acts in ways that are not fully predictable e.g. feedback loops

• Influenced by history • Self-organising • Resistant to change

   

 

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ANTWERP MODEL: Van Olmen et al. 2010

   

 

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COLLECTIVE MEDIATOR

HEALTH CARE PROVIDERS

ORGANISATION

POPULATION

ORGANISATION

RESOURCE GENERATORS

OTHER SECTORS

Basis for eligibility

Degree of control

Degree of control

Degree of control

Taxes, Demands for services

Services with health effects

Subsidies, Information, Ideologies

Potential personnel, money, data

Schemes for interpreting human experience

Human resources, Payment mechanisms, Scientific information, Technology

Formal health servicesCommunity participation

Frenk, 1994

Competition for responsibilities and resources

   

 

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Systems ‘Software’Ideas and interests, Values and norms Relationships 

and power, 

Systems ‘Hardware’Human Resources, Finance, Medicines & technology, Organizational structure, Service infrastructure, Information systems

International

National

Subnational

Local

ARENA3. SOCIAL CONSTRUCTION

Policy and systems are shaped by particular politics, culture, discourse (and not others)

Policy (and systems) can be problematized

Suggests solutions within and beyond health systems

(Sheikh et al. 2011)

   

 

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People Centred Health Systems

1. Putting people’s voices and needs first

2. People-centredness in service delivery

3. Relationships matter: health systems as social institutions

4. Values drive people-centred health systems

   

 

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 1. PUTTING PEOPLE’S

VOICES & NEEDS FIRST

How can people’s voices influence shaping the health

systems to serve public interest?

• Back to PHC approach: equality, rights, health as socio-economic issue

• Confronting disproportionate power balances

• Participation  Participatory governance

2. PEOPLE-CENTREDNESS IN SERVICE DELIVERY

Putting people first in terms of how services are designed and delivered,

not merely orienting services on basis of diseases, or for

convenience of clinicians

• Quality and safety of care• “Longitudinality”, closeness to 

communities, responsiveness to users’ views, requirements 

• Capacity building as enhancing capabilities for responsiveness

   

 

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 3. HEALTH SYSTEMS AS SOCIAL INSTITUTIONS

Health systems actors – administrators, providers, users, researchers – are linked through

relationships

• Systems thrive on trust, dialogue between actors, 

• System change goes beyond altering rules & resources, to managing relationships effectively 

4. VALUES DRIVE PEOPLE-CENTREDNESS

Decision-making should be informed by people-centred values:

justice, respect, inclusiveness

• Values define system culture and influence perfomance

• Procedural justice complements distributional justice, in a people-centred system 

   

 

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HEALTH POLICY FRAMEWORKS

   

 

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The Health Policy “Triangle”

CONTENT

ACTORS

• as individuals•as members of groups

PROCESSCONTEXT

(Walt and Gilson 1994)

   

 

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Stages of Policy

POLICY PROCESSESAgenda 

setting

Policy-making

Implementation

   

 

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Types of Policies

• Distributive / redistributive: concerned with the distribution of new resources or with changing the distribution of existing resources

• Regulatory: concerned with the control of individual and organization activities

• Constituent: concerned with setting up and re-organizing institutions

From Lowi (1972)

   

 

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Top-down and Bottom-up policy

Top Down

• Policy-making and implementation are distinct

• Focus on execution of policy-makers’ intentions 

• Starts with a statement of intent 

• Implementation with clear lines of authority and enforcement of norms

Bottom Up

• No clear separation between policymaking, implementation

• Subordinate actors (e.g. service providers) also seen as decision-makers

• Starts with a statement of behavior in the ‘field’

• Implementation seen as relationships between actors 

   

 

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Policy Actors

Governments

Lawmakers Executive Judiciary

Ministries and bureaucracy

Institutions, firms and organizations

Technical and professional bodies

Donor agencies

Civil society and interest groups

‘Networks’

‘Street level bureaucrats’

Laity / electorate

Multilateral / bilateral organizations

NON-STATE

STATE

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